| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency's self-assessment completed for this home between 10/23/24 to 11/10/24, did not provide a written summary of corrections made for any of the following regulation items identified as violations: 6400.46a; 6400.46b; 6400.51a6; and 6400.151a. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Staff Person #2: 6 Feb 2025- Hire date was 22 May 2024, so it has not been 12 months since date of hire: hence agency in COMPLIANANCE with regulations.
Staff Person #3: 6 Feb 2025- Trained in agency's General Fire Safety curriculum on 23 May 2024, hence not in violation. The hire date was 23 May 2024, so it has not been 12 months since date of hire: hence agency in COMPLIANANCE with regulations.
Staff Person #4: 6 Feb 2025- Hire date was 25 Jul 2024, and New Hire Orientation training was completed 29 Jul 2024; hence agency in COMPLIANCE with regulations.
Staff Person #1: The Self-Inspection for Code violation 6400.151a, the physicals were accidentally read in the reverse order. (Please SEE Supporting Document), hence not in violation. |
02/19/2025
| Implemented |
| 6400.66 | At 10:11 AM on 1/23/2025, there was not a source of outside lighting at the sliding glass door in the dining room leading to the deck in the rear of the home. [Repeat Violation, 1/25/2024] | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The Maintenance person (Sub-Contractor) installed a new Solar motion light detector (Please SEE Picture) outside of the rear sliding glass door leading to the deck in the rear of the home. We now have two Solar motion light detectors installed outside in the back. An Invoice was issued by the contractor on 21 February 2025 that showed the work was completed. In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 for the duties of going to the Woodcliffe home quarterly throughout the year to ensure that the light fixtures are operable outside of the sliding door are working properly with compliant code 6400.66. |
02/21/2025
| Implemented |
| 6400.68(b) | At 10:30 AM on 1/23/2025, the hot water temperature at the bathtub in the full bathroom on the home's upper level measured 131.9°F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The Maintenance person (Sub-Contractor) replaced the temperature valve in the shower on 3 February 2025 and reset the limit on the hot water between 110 -112 degrees Fahrenheit. An Invoice was issued by the contractor on 21 February 2025 that showed the work was completed. In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 for the duties of going to the Woodcliffe home quarterly throughout the year to ensure that the temperature valve in the shower is working properly with compliant code 6400.68(b). |
02/21/2025
| Implemented |
| 6400.101 | At 10:10 AM on 1/23/2025, the sliding glass door leading from the dining room to the rear deck was equipped with a foot-pedal brake track lock installed on its bottom right corner, requiring a kicking motion to depress a button for the lock to disengage, posing an obstructed or "choke point" at the egress. [Repeat Violation, 1/25/2024] | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The Maintenance person (Sub-Contractor) removed the foot-pedal lock on the sliding glass door leading from the dining room to the rear deck on 3 February 2025. A Paid Invoice with the completed installation of removing the foot-pedal lock was issued on 21 February 2025. In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 for the duties of going to each home quarterly throughout the year to ensure that there are no foot-pedal locks on any sliding doors. The training/consolation form was signed and dated by the contractor on 21 February 2025. |
02/21/2025
| Implemented |
| 6400.106 | The home's furnace inspection, completed 9/12/2024 did not include a cleaning. The invoice service note read, "The unit is working properly at this time, adjusted fan speed to a high speed. Job completed." | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The CFO contacted the Heating & Air Conditioning Company to instruct them to correct the maintenance Invoices to say, "cleaning" on the documents. The annual Inspection from the heating company on 6 February 2025 documented the Maintenance Invoices to reflect, "cleaning" for all of the furnaces. (Please SEE Documents). |
02/06/2025
| Implemented |
| 6400.107 | At 10:30 AM on 1/23/2025, there was a portable electric space heater with an exposed external cord installed in the recessed cavity of a faux fireplace in the staff office in the home. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| The Maintenance person (Sub-Contractor) cut the cord on the fireplace blower and disconnected it. A Paid Invoice with the removal of the cord on the fireplace blower was issued on 21 February 2025. the Site Operations Managers were given a counseling session by the CFO to instruct their Direct Support Staff to check for portable space heaters in the homes and remove them, immediately if found. The counseling/training form was signed and dated 24 February 2025. |
02/24/2025
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed 3/11/2024, did not include an assessment of individual #1's health maintenance needs, medication regimen, and the need for blood work at recommended intervals. These sections were left blank. [Repeat Violation, 1/25/2024] | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Individual #1¿s physical examination completed on 3/11/2024 did not include information from the physician for health maintenance needs, medication regimen, and need for blood work and recommended intervals. These sections were left blank by the physician. Site Operations Manager has taken over the Physical dated 3/11/2024 to the PCP office and asked that it is completed by the PCP in its entirety on 2/10/2025 Per 55 Code Chapter 6400.141(c)(11). Site Operations Manager received back the Annual Physical completed 2/10/2025 before leaving the Physicians office. Site Operations Manager checked all other individual physical forms to ensure all areas of the annual physical were completed by the PCP and were in good standing. |
02/24/2025
| Implemented |
| 6400.142(d) | Individual #1's dental examinations, completed on 6/26/2023 and 1/25/2024 did not include teeth cleanings or the checking of gums and dentures. | The dental examination shall include teeth cleaning or checking gums and dentures. | Individual # 1 had a dental exam on 6/26/2023 and then again on 1/25/2024 that did not include teeth cleanings, or checking of gums and dentures. Site Operations Manager has scheduled Individual #1¿s next appointment so that Individual #1 is complaint with all dental appointments and receiving dental examinations that includes teeth cleaning or checking gums and dentures Per 55 Code Chapter 6400.142(a) |
02/25/2025
| Implemented |
| 6400.181(d) | Individual #1's current assessment, completed on 12/9/2024, was not signed and dated by the Program Specialist. [Repeat Violation, 1/25/24] | The program specialist shall sign and date the assessment. | Individual #1¿s current assessment, completed on 12/9/2024 was signed by the Program Specialist on 2/5/2025. Program Specialist has since reviewed all Skill Assessments and made sure all Program Specialist signatures were signed and dated for 2/5/2025, Per 55 PA Code Chapter 6400.181(d). |
02/24/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's current assessment, completed on 12/9/2024, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Individual #1¿s current assessment, completed on 12/9/2024 did not include Individual #1¿s Lifetime Medical History. Individual #1¿s current Skill Assessment was changed by the Program Specialist 2/5/2025 to reflect Individual #1¿s Lifetime Medica; History per 55 PA Code Chapter 6400.181(e)(10). This documentation has been sent to the SC for all corrected information on 2/25/2025. |
02/24/2025
| Implemented |
| 6400.213(3) | Individual #1 had a gynecological examination on 1/14/2024; however, the medical documentation of the physical examination was not kept in Individual #1's record. | Each individual's record must include the following information: Physical examinations.
| Individual #1's gynecological examination on 1/14/2024 was not kept in the individual #1's record. The Site Operations Manager has immediately corrected this and placed all documentation in Individual #1's record Per 55 Code Chapter 6400.013(3). Site Operations Manager has checked all other Individual files to ensure that all Physical examinations were in the Individual's record. |
02/25/2025
| Implemented |
| 6400.46(d) | Program Specialist #1 completed two-year certification training from the American Red Cross in first aid, Heimlich techniques, and cardio-pulmonary resuscitation on 9/29/2022, and then again on 12/5/2024. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Program Specialist #1 completed American Red Cross and First Aid, Heimlich techniques, and cardio pulmonary resuscitation on 12/5/2024 Per 55 Code Chapter 6400.46(d). |
02/25/2025
| Implemented |
| 6400.182(c) | Individual #1's Individual Support Plan last updated on 12/10/2024 stated that they require verbal and gestural prompting to evacuate safely in the event of a fire. Individual #1's assessment completed 12/9/2024 indicated Individual #1 can evacuate independently without assistance. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Individual #1¿s Individual Support Plan, that was updated on 12/10/2024 and Skill Assessment that was completed 12/9/2024 was updated on 2/5/2025 to reflect information about Individual #1¿s ability to evacuate independently without assistance Per 55 PA Code Chapter 6400.182(c). Program Specialist SC for all corrected information on 2/25/2025. |
02/24/2025
| Implemented |